NCC192188_Notice of Termination_20211001

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 10/1/2021 11:30:14 AM (NOT Submittal)
Approve by Morman, Alaina 10/5/2021 8:09:28 AM (NOT Request Review- NCC192188)
• The task was assigned to Morman, Alaina. The due date is: October 6, 2021 5:00 PM
10/1/2021 11:30 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC192188
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status PAID
2021 Annual Fee Status OPEN
Nby be blank (if not yet billed).
Information associated with this permit:
Project Name
CMPD Independence Division
Address
5809 E. Independence Blvd., Charlotte, NC
County
Mecklenburg
Latitude
35.0000
Longitude
-81.0000
Permittee Listed
City of Charlotte
Legally Responsible
Kathleen Cishek
Individual
NC Reference No.
NCG01-2019-2188
E&SC Plan ID
MECKL-2020-028
Original NOI
16680
Tracking No.
Date COC Issued
10/8/2019
Prior Rescission
Cate populates only if COCwas already rescinded at time of submittal.
Date
Reason for Rescission/Termination Request:
Reason for
r Project Closed -Out
Termination of
r Sale (Another Owner/Operator obtained a new COC)
Coverage *
r Mistake or Invalid Coverage
r Other
Additional IVbre information about the basis of this request, if needed.
Explanation
Supporting upload Supporting Documentation if applicable.
Documentation Mist beRYforrrat

Project Close-out Information:
Final Close-out 1/28/2021
Inspection Approval
Project Close-out Final NCDENR Inspection Report MECKL-2020-
Approval 114.27KB
029_CMPD Independence CO_1.28.2021.pdf
Documentation
Mist be FDFforrrat
North Carolina General Statute 143-215.66 (1) provides that:
Anyperson who knowinglymakes any false statement, representation, or certification in anyapplication, record, report, plan, or other
documentfiled or required to be maintained under this Article or a rule implementing this Article; or who knowingly makes a false statement
of a material fact in a rulemaking proceeding or contested case underthis Article; or who falsifies, tampers with, or knowingly renders
inaccurate any recording or monitoring deice or method required to be operated or maintained under this Article or rules ofthe
Commission implementing this Article shall be guiltyofa Class 2 misdemeanor which mayinclude a fine not to exceed ten thousand
dollars ($10,000).
rJ I, as an authorized representative, hereby request rescission of coverage under
the NPDES Stormwater Permit for the subject facility. I am familiar with the
information contained in this request and to the best of my knowledge and
belief such information is true, complete and accurate.
*This form must be signed by a responsible corporate officer that owns or operates the construction activity, such as a
president, secretary, treasurer, or vice president, or a manager that is authorized in accordance with Part IV, Section B,
Item (6) of the NCG010000 General Permit. For more information on signatory requirements, see Part IV, Section B,
Item (6) of that permit.
Signature
Type Name* Bruce E. Miller
Title * Sr. Project Manager
Organization * City of Charlotte/General Services
Date * 10/01 /2021
Email for [e-mail]
Confirmation *
Contact Telephone* 7049076806
NOT Certification NCG01-eNOT-Certification-Form-20210514-
Form DEMLR-SW Signed.pdf
Mist be FDF Fbrnat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Errails
(Optional) [e-mail]
Original Permittee CCdonWificationErrails
Email [e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]
349.47KB